The faces of "Maternal Mortality"

I am back now, in Canada, in the arms of my family and have some final reflections to share - written on the plane back from Uganda.

We are so separate from maternal death in Canada. In Uganda, it is a tangible spectre that haunts everyone involved. The staff, the women, the families.

We say in Canada that our biggest goal is "healthy mom, healthy baby." In Uganda, it is "live mom, live baby."

On our way to safari, we chat idly in our Canadian way, trying to build some camaraderie via reports of our terribly busy and important work. Our tiredness and hard work is constantly commented on by the hotel staff (who are up long before we are and work late into the night, long after we are in our beds).

We say to our driver (because we are headed on safari and we feel we deserve it. We work so hard, we see unspeakable things, we crave a swimming pool and a change of scenery)... we say we have "had a hard week. A mother has died of bleeding after childbirth."

Our driver says "yes, that happens here. That is how my wife died. Five years ago."

We die a little inside.

"I am so sorry"

"It's okay. It's okay," he says, going to fill the safari van with diesel and rocking the van to get the tank really full.

We sit with our hearts beating, the weight of reality pressing down on us.

It's not f---ing okay.

Of course not. But he is okay. He survives. He has not taken another wife because his children are still too young, he feels, and a stepmother will mistreat them. But he hopes for another wife one day. Maybe four.

I picture the woman who works at the hotel working the buffet. One day, I see her half-hidden behind the pillar, picking up one foot, and then the other to relieve the tiredness. I'll bet I sit more that she does in my daily work.

She is a sunny person. I often catch her quietly watching us. watching me, smilling at our banter and jokes. "You are well?" she asks. "We are burungi!!" [fine]

One evening she comes to our table. Sadness roles off her like fog. Carole says "are you okay??"

She pauses... it hangs in the air. Says ".......................no" and steps back just a little. It's that moment where you ask someone how they are and the surface cracks like glass at your tone or your body language and you get a painfully honest answer.

"My sister died."

"Oh no, I am so sorry"
"What happened?"

"Hypertension"

I look at this young woman standing beside me.

"Was she...pregnant?"

"Yes"

"Oh. no.
"Does she have other childen?"

Turns out her sister was 33 years old, leaving three older children and was buried on Sunday.

The connect is lost and she backs aways from the table like a ghost and doesn't meet our eyes for the rest of the night.

We feel the weight pressing down on us and look up pregnancy-induced hypertension in our texts at the table.

Thinking "....... Why?"

Why are they crying?

On Canada Day, we saw a woman take her last breaths.

We went to Lower Mulago with our Canadian flag pins on our chests (over the heart) [nothing seems to make you more patriotic than being away from home]. I have a bad feeling in my stomach (not related to unwashed produce) but to Cathy saying earlier that something bad usually happens on the last day on Lower Mulago.

As we walked into the room, these two non-ugandan students are sitting by the door on the bench. "oh my gosh - are you from Canada?!"

We are and they are - they are pre-med doing overseas observational placement. The purpose of observing escapes me somewhat. The only thing that keeps me sane here is knowing that at the very least I can do SOMETHING.

They chat with us and say that the woman in the first bed has lost some blood and they are looking for blood for her. She is lying with her eyes shut, breathing evenly. I don't even notice that the baby is there, lying at the foot of the bed.

So, to make and long, sad story shorter and no less sad --- she very quickly goes very downhill and dies. They can't take our blood, even though they ask for special permission. It is too late, anyhow.

I wrap the baby boy with Jody in one of our donated blankets - hating that this is the story of his birth, hoping he will be okay.

I keep myself busy the only way I know how, by working, and managing to choose the most complicated woman to help. The one who refuses all vaginal exams, the one who has not been examined in 2 days of attempts. The one whose full, full bladder is not only palpable but visible from 20 feet away.

She tells me that men have damaged her, that the doctors damaged her, that she was beaten by her mother, that it happened many years ago, that it was in the last 2 days. I do a vag exam with my pinky only (seriously) - which tells me that there is a head, low, and no cervix at the front. That's it. That is all that she can take. I do a cathetar with super sonic speed for the full, full inital bladder. She pushes for an hour, about as long as Cathy says we can let her. She is okay with me, says I am a kind one - then tells me that she will have a ceasar if I do it only, that no one else can touch her. Shit. Not going to happen. There is meconium now draining with the amniotic fluid. Shit. I ask for a consult, and the consultant does the first full VE on her (she is fighting and refusing and crushing my hand) and there is caput and mec and she is on the list for section. I am relieved, because as much as I wanted this to be a healing birth for her, the writing is on the wall. The fetal heart is consistently good. 130 140 130 150 140

I do a 2nd cathetar with super sonic speed - to prep for the inevitable surgery. That 2nd cathetar drains red bloody urine. Shit.

The soundtrack of our day is the weeping and wailing of utter grief from the dead woman's family. Desperately sad and angry tones echo and the rain pours down like tears.

She asks me why those people are crying in the hall and in the breezeway.

"Why are they crying?.... Did they lose their baby?"

"I don't know," I say, " Sorry, I can't understand what they are saying"

She listens carefully and quietly. I think she has forgotten about it.

Then she says:

"I know! They are crying because Michael Jackson has died!... I, too, am sad."



I spent hours with her, and left her, prepped for surgery, next on the list to go, with a good fetal heart rate. That was all that I could do. Sometimes that is all you can do.

Childbirth Numbers Uganda style

Rural hospitals here have like 20 births a day. Many rural hospitals in BC have 20 births/month.

Mulago hospital does like 120 births in 24 hours. Crazy.

In Mulago, we have had two sets of twins in the same day. In Masaka, we have had 3 breeches in the same week.

We now all have our numbers to “graduate.”

Although, technically, I do also need one more continuity of care. Which my husband kindly reminded me when I was "mentioning it." Thanks, honey.

We have seen so much here and been with so many women in labour -- women of every circumstance.

Women with large, supportive families, and women who have nobody. Nobody.

I have supported women who were accountants and teachers and also women whose occupations were listed as:

-"peasant"
-"housewife"
- and my favorite...... "hawker"

I have supported women who were closer to my children in age, than to me.

And I have supported women who were prematurely aged beyond what I would have thought possible. Aged by hardship and poverty and hard physical work and personal sadness.

I have supported a Gravida 10, Para 9, through a safe birth and to a healthy baby, only to find out later that 5 of her other children had died in early infancy. And this baby was now back in to the hospital, admitted to the nursery and very sick.

So many stories.

HIV testing

I went to antenatal and learned about HIV testing. The tests are like pregnancy tests and give results in 30 minutes. In Kampala, I watched as the blood samples from 7 pregnant women and their 7 husbands were tested. I watched the control lines turn and saw 13 negative tests. And one that was positive.

The positive was one of the women and her husband was negative. I talked to the lab tech about what they do. He retested the husband and wife’s samples with all three of the available types of tests. She was confirmed as positive and he was negative. And sitting right outside. Waiting.

The system is that the couples or women arrive, are interviewed for a health history, go to a pre-test counselling session, go to the lab for the HIV blood draw, wait for the results, go to post-test counselling to receive the results, then go get palpated, get their BP taken and then go.
It was a cruddy feeling knowing that someone’s life was about to change forever. But better to know. And the perinatal period is a window for accessing women for testing, and a critical time to know status for reducing mother to child transmission.

As I went back later to show Carole the lab, I saw an increasing pile of test strips on the counter and on one perforated card 5 of 10 tests were positive.

“You do not have this struggle in Canada”

“You must clearly label the husband and wife’s tests as you do not want to give the wrong person the disease.”

Bad Moment

I was at the high risk ward at Mulago Hospital with Jody and Angela (preceptor). The obstetricians were just doing Rounds with the Residents and medical students. There were about 6 of them grouped at the end of one bed. They finished with that mother and casually said "We can't hear the fetal heart, but it doesnt mean the baby is dead. The head is right there. She will deliver soon." I asked one of the Residents if I could try to detect the fetal heart with my fetoscope (can usually pick up sounds better than the pinard that is used here in Uganda). He said sure and I grabbed my fetoscope and went back to the bed. As I got there, I realized that the mother was silently pushing and the baby's head was already partially out. I called out "Help, somebody,the head is right there." The group of doctors at the bed right beside me didnt even turn around. I was not gloved, had no ties, no cloths to wipe baby dry, no razor, no oxytocin. I was telling the mother to "TOE SINDACA" (DONT PUSH), and managed to get my gloves on (at least one hand double gloved). Jody and Angela were trying to get on gloves - they had been putting an IV into another woman. I guided the little body out and knew right away he wasn't breathing. I was calling for help, and the group of doctors still didnt turn around. One man glanced over his shoulder as my voice got more urgent, and then turned away. "We need a resus here" I told Jody and Angela. By then, they were there, with the few very important items we needed. I cut the cord and Angela and Jody ran with the baby to the resuscitation room. Despite 10 minutes of positive pressure ventilation and chest compressions, the little boy never took a breath, never had a heartbeat. They had to come back and tell the mother, who sobbed and sobbed. The doctors never looked at her again. I was so very angry. It was said best by one of the head obstetricians at a meeting we had been at another day - Doctors here must start treating EVERY woman like their relative if there are to be changes in obstetrical care here in Uganda.

Tina

The Other Side of Working in Uganda

Many of you tell us you have been keeping up with our posts so for those of you who have, you will know we have tried to mix up the things we've posted. We have funny posts, descriptions of Ugandan life and lots of birth stories. It is only now that I feel like I can post on my reflections on the harder side of working in the free hospital in an undeveloped country (if you like that term)in a major city.

Birth here for the most part happens well, narcotic free, and both mother and baby are okay - particularly in Ward 14 where we work. This ward is considered low risk and it is staffed exclusively by midwives. There is no obstetrician, no operating room and no pain medication. We have worked for 6 weeks without instruments and often we do not have supplies first thing in the morning (with shift change). But since we travel with our basic supplies (gloves, medication etc...) it is rare that the what we need is not available at all (its more likely they are in safe keeping for a "real" emergency).

Sometime though, this isn't the case. Like the day we walked in to the high risk labour room and a mother, who had bled for hours after delivery, took her last breaths. Sarah and Cathy had the same blood type and offered to do a transfusion but it was too late. I wrapped her baby while the rest of our team helped with the mom. Minutes later we could hear the yells of the family outside - which continued for what felt like hours. Someone commented that luckily the baby was a boy - if not the family might have chosen not to take the baby home.

The next day Tina and I went to rounds and both of us felt the impact of hearing that the mother's death could have been prevented. Perhaps earlier action? but at the very least just getting her a blood transfusion (the hospital was out of her blood type). This would not have happened at home.

The other part of our work that I find most troubling is seeing babies born to ill (e.g. malaria in pregnancy) or malnourished moms. In our country again this normally doesn't happen. Where it does, a care provider often will have "caught" the problem and supports can be put in place. Here there is no one who is consistently able to help other than family, if they can afford it, and it seems most women coming to the busy free hospital are from families who are not able to help.

One recent example is Fatima's baby. He was born earlier this week and Tina and I happened to be hanging around for the birth - another medical student was catching. When he was delivered he needed to be resucitated and had many other problems. The next day we found out he needed an ultrasound that the mother could not afford. So Tina and I paid 10,000 shillings ($5 USD) and he is now being referred to a specialist. If the specialist recommends follow-up tests or surgery what will happen to that baby? Will the family be able to afford to get him care?

The reality here is much different in many ways and yet the experience of birth in Uganda has touched me not only in these ways but in the same way birth does at home. The strength of the women and their resilience is truly inspiring. Each birth brings learning to my life, joy to my heart and peace to my soul. I hope in some way the moms and midwives I worked with in my time here understand how much they have given me and I hope I have helped in some little way to make their journey better.

Jody

Suck it up Buttercup

One of our new favorite sayings on our trip has been Suck it up Buttercup - which has now just been shortened to using Buttercup as a nick name anytime one of us starts whining about our "troubles" in Uganda. Read this post and then our next one and you will see why there has been little sympathy for our "tough" times.

Here are the Buttercup moments we've had so far:

- eating white toast and a boiled egg for 39 days in a row;
- white shirts, shoes and our feet permamently stained an odd orange/brown colour;
- random sewage (and other) smells and leaping an open sewer every day en route to the hospital;
- soaping up to discover there isn't enough water to wash the shampoo from our hair;
- not having a toilet seat for almost 3 weeks;
- working in Labour & Delivery, with lots of bodily fluids, and no running water; and
- almost being run over by a Boda-Boda (again).

Perspective

One of the things I noticed when I first arrived in Uganda was the scarcity of people around my own age, early 50's. Cathy Ellis explained that many people of that generation were wiped out in the original AIDS epidemic. Uganda today is a leader in Africa for actually reducing the rate of people with AIDS. On the wards, we are all acutely aware of the risk of infection. We are taught how to protect ourselves: double gloving, careful disposal of sharps, awareness of all body fluids, eye protection, rubber aprons for delivery, hand washing, anti-bacterial gels. One of the first things we check on a chart is the woman's "TR" status - "TR" means tested negative for HIV, "TRR" means tested positive for HIV. One day last week, we attended 6 young women. Two were having their first baby, 1 was having her second baby, and 3 were having their third baby. All were between the ages of 19 and 23. Five out of the 6 were positive for HIV. As I tended to these women, I wasn't thinking anymore about my risk. I was protected from head to toe. Instead I was thinking about those 5 young women, infected with HIV, their newborn child and their families at home. That is the real tragedy.

Tina

Blue flowered dress Girl

On one of our crazy days on lower mulago, we were running off our feet and trying to triage all the labouring women. This girl in a blue flowered dress was labouring away, alone, all day in a middle bed. We kept asking, each of us, what is the deal with the blue flowered dress?

"PG (primagravida), 4 cms"

and we would have to move past her to deal with the 9cms with bulging membranes that continually come through the door. Over and over.

At the end of the day, Carole was finally able to look at her chart and read that she was 15 yrs old. And "single." Carole was so moved, as the mother of a 15 year old boy, to think of her child being in that situation.

Sarah for Carole.

Remember blue flowered dress girl. We will.

Hand-washing our big girl panties...in the dark

So, Carole and I are back in Masaka for our last week of catching those babies. We had a nice 4 day adventure to see some animals, and are now working hard. The hotel has had frequent power outages, so that makes our evenings exciting! Sigh.

For some reason, the birth gods are kicking our butt and there have been lots of mamas and babies to attend to. We were very busy on Monday and Tuesday, but only 1 birth today. Lots of c-sections for failed trial of scar.

We had some sadness. Yesterday afternoon, a fresh still birth was carried in from a uterine rupture that was transferred in. This morning we found out that the mother had died. The baby was unclaimed all day. Sad sad sad.

We made friends with a sweet little 4 day old baby with Vit K deficiency bleeding. He was very unwell but quite a scrappy little guy. Carole nicknamed him "Spike" because there was a bulldog on the little hat we gave him. So, think of Spike tonight and we hope and pray he is okay tomorrow.

Sarah

Big Girl Panties

On Monday Tina and I put on our “big girl panties” and made our way to the hospital for the start of our time without preceptors. It was a tough experience with 4 out of 5 births including unnecessary episiotomies (cuts to the woman’s perineum) done by the hospital staff (not us!). We were worried to say the least. But by the end of the week we are pleased to be conducting the births on our own and even managing problems like post partum haemorrhage and shoulder dystocia.

We’ve been asked to talk to the staff about how we chart and why – the head Midwife likes what we’ve been taught (thanks UBC and our various preceptors). They are also interested in us demonstrating sterile water injections for women with back labour (I’m injecting Tina of course). We’ve moved from the role of students to colleagues. The midwives are even calling us “Sister” – a term of respect. We are both very excited about our final week here in the hospital and in Kampala.

We are much more comfortable in the city, on the streets and at the markets. We’ve even found our own short cuts and have walked at least half of the city. We even bargained for a pineapple from a guy on the road with a wheelbarrow full (saved twenty cents at least). Now we are counting down - 9 sleeps (and who knows how many babies) until we are home.

Jody and Tina

Ugandan Road Hierarchy

(in increasing order of importance)

Pedestrians - Lowest of the low. Step onto road at your own peril. Even if you are halfway across, whatever is approaching you at top speed has the right of way.

Bicycles – Low. Must give way to everything except a pedestrian, including flinging self and bicycle into bushes on the side of the road to avoid impact.

Boda-Boda – Actually 2 designations. Lowest of all motorized vehicles. Highest of all non-motorized users. Will actively run pedestrians off paths, leap unbidden between rows of traffic, run the wrong way on the streets, use sidewalks instead of roads, carry treacherously wide loads of sugar cane, swerve endlessly directly at the mzungo (foreigner) from any direction to offer a ride.

Cars – Medium. Have to be vigilant for bigger vehicles.

Trucks/Matatu (small buses). Medium-high. By dint of their heavy exhaust and slow uphill speeds they can cause road chaos behind them.

Big Buses. High. These vehicles go at high speeds wherever and whenever they want to, including passing up hills, around curves, when there is no room, when there is oncoming traffic, forcing everyone else below them on the hierarchy to GET-OUT-OF-THE-WAY.

Chickens. Highest. Will bring even the biggest buses to a halt to give the poor chickens time to get across the road.

Sharp Sharp, Where’s the Sharp?

One of the first things we learn as health care providers is to properly dispose of your sharp. A sharp is defined as anything that could cut skin. Examples include a needle, a broken vial of medication, the top off a broken vial or even used razors. Here in hospital things are a bit different. We quickly learned to play the game “Sharp Sharp, Where’s the Sharp?” For reasons we don’t understand, disposal of sharps here is very casual, and therefore, incredibly dangerous. It could be here, it could be there, in fact it could be anywhere. Underfoot, underhand, on windowsill or hiding in with clean supplies. So we remain ever vigilant and have learned to start our day with a quick round of the game and have repeated rounds throughout the day as necessary.

Tina and Jody